Healthcare Provider Details

I. General information

NPI: 1659796860
Provider Name (Legal Business Name): FUNDAMENTAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 01/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N MAIN ST
PICAYUNE MS
39466-3313
US

IV. Provider business mailing address

20 NEWT MITCHELL RD
PICAYUNE MS
39466-9224
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-4065
  • Fax: 601-620-4117
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT2316
License Number StateMS

VIII. Authorized Official

Name: MRS. SARA CARR BRADDY
Title or Position: OCCUPATIONAL THERAPIST
Credential: MOTR/L
Phone: 601-916-8329